State fears there's more pregnancy-related deaths than have been reported

In the United States, maternal mortality is becoming more of a focus for many health officials. Here in Delaware, a maternal mortality review committee is working with the CDC to better understand these deaths in The First State.
Meredith Newman, News Journal

Delaware's maternal mortality review committee is working with the CDC to better understand pregnancy-related deaths.(Photo: Stockstudio)

"It's the tip of the iceberg for a cascade of women's health issues," said Dr. Meena Ramakrishnan, who helps review maternal mortality cases in Delaware.

"Through a close study of why maternal deaths occurred, we learn more about conditions that are prevalent in more women who don't die from it," she said. "It's a window to look into women's health."

The Centers for Disease Control and Prevention has found that nationally 700 women die during pregnancy, delivery or soon after delivering every year. In Delaware, some reports indicate it's up to four to five deaths a year, but could be more.

The state’s maternal mortality review committee is looking into two different types of cases. The first is pregnancy-related, or when a woman who is pregnant or a year postpartum dies from a condition that is related to or stems from pregnancy, such as a hemorrhage. The second is pregnancy-associated, which is when a woman who is pregnant or recently pregnant dies but it's not related to the pregnancy. An example of this could be a car accident.

This review team then determines what factors led to the woman's death, looks for possible trends and develops recommendations. Unlike other review committees across the country, Delaware's group has subpoena power to collect information about the mother and her circumstances.

A majority of these cases were first identified by the pregnancy checkbox on death certificates, but the committee and the CDC have found that this checkbox often inaccurately identifies if the woman was pregnant recently or not.

Anne Pedrick, executive director of the Child Death Review Commission that oversees the team, said the numbers could be low because some medical providers are at times unaware that a woman was pregnant in the last year.

"It’s not just a unique problem in Delaware," Pedrick said. "It’s across the country nationally that this is a struggle."

Because of this, the state is now looking to find maternal mortality cases through different sources, including newborn birth certificates, said Dr. Garrett Colmorgen, chairman of the Child Death Review Commission.

The committee will also take a deeper look into factors that contributed to pregnancy-related or pregnancy-associated deaths, Colmorgen said. The group met with CDC officials earlier this month about how to look at maternal deaths more critically.

The committee will now use a form by the CDC that looks into a myriad of factors, ranging from the patient's family life to the provider's care and the healthcare facilities' services. And it requires specifics: For example, if the mother died from suicide, homicide or an accidental death, the committee should indicate what caused the fatal injury, such as a firearm, car or blunt instrument.

It also makes the review committee form specific recommendations on what could have been done to change the course of events that led to the death.

“It’s forced us to change the way we look at things," Colmorgen said. Now, some cases that might have once been deemed unpreventable could be considered preventable, he said.

This could include realizing there was poor communication among health providers or factoring in the lack of support from a patient’s family.

Ramakrishnan, a consultant for the maternal mortality review committee, said postpartum is often a vulnerable time for women since their bodies are still recuperating from giving birth and adjusting to "the new normal."

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After giving birth, women are also dealing with a flood of hormones, often resulting in mood swings. Sometimes, hormonal changes can cause conditions such as postpartum depression.

Almost 65 percent of pregnancy-related deaths occurred within 42 days of postpartum, according to state data. Since 2009, four of the deaths occurred because of cardiovascular and coronary conditions while two deaths were caused by pulmonary conditions. The other eight deaths were caused by various medical issues.

Postpartum can also heighten the psychosocial factors for some women, Ramakrishnan said.

Of the two dozen pregnancy-related and pregnancy-associated deaths in Delaware, six involved substance abuse issues, seven involved mental health issues and three cases involved domestic violence.

While analyzing the data, the committee noticed that coordination of care has played a factor in some of these deaths, Ramakrishnan said. There have been cases where a new mom goes to the emergency department for a medical issue and that information is never passed along to her primary care physician, she said.

Colmorgen, the director of obstetrics and maternal-fetal medicine at Bayhealth, said he would like to see the review committee eventually work with hospitals about reducing pregnancy-related deaths in Delaware. Right now, it's hard to give recommendations since there's a small amount of data, he said.

Colmorgen said the work of the committee can often be challenging because it "emphasizes the need ... and it makes you upset about what you can’t do." One example includes screening for postpartum depression.